New guideline issued for the management of functional seizures

To help neurologists, mental health clinicians and other clinicians determine the best ways to help people manage functional seizures, the American Academy of Neurology has issued a new guideline. Published in Neurology, the guideline is endorsed by the American Epilepsy Society.

Functional seizures, previously known as psychogenic nonepileptic seizures or non-epileptic attack disorder, are episodes that can look or feel like epilepsy or fainting, but with different causes and their own typical features.

"There is a growing body of evidence demonstrating that potentially effective treatments are available for functional seizures once an accurate diagnosis is made," said guideline author Benjamin Tolchin, MD, MS, of the Yale School of Medicine in New Haven, Connecticut, and a Fellow of the American Academy of Neurology.

"Nevertheless, most people with functional seizures do not receive targeted and evidence-based treatment, contributing to ongoing functional seizures and disability. Functional seizures have been a misunderstood condition, and this AAN guideline is a landmark effort to help overcome that stigma."

The guideline is based on a careful review of the available evidence on the topic. The review found that psychological interventions are possibly effective in increasing the likelihood of achieving freedom from functional seizures, decreasing the frequency of functional seizures, decreasing anxiety and improving quality of life for people with functional seizures.

Potentially effective psychological interventions include functional seizure–specific cognitive behavioral therapies, neurobehavioral therapy, paradoxical therapy, and motivational interviewing in combination with psychotherapy.

To help determine whether a person is having functional seizures, seizures due to epilepsy, or a combination of both, the guideline recommends that clinicians ask people about the details of their seizures. This includes interviewing people who have witnessed the seizures, requesting any smartphone videos of the seizures and possibly conducting tests such as a video electroencephalogram (EEG).

It states that people diagnosed with functional seizures should also be evaluated for co-occurring epilepsy and psychiatric disorders.

The guideline recommends that a diagnosis is provided in a manner that is clear, empathetic and supportive. It also recommends that, if appropriate, family and other care partners of the person with functional seizures be included in decisions about treatment.

The guideline says when psychological interventions such as cognitive behavioral therapy are indicated, clinicians should counsel people about the benefits and risks. It states that psychological interventions are generally safe and well tolerated.

The guideline recommends that antiseizure medications such as benzodiazepines should not be prescribed for functional seizures without co-occurring epilepsy or another reason for these medications. It says people should be counseled about the potential risks and lack of evidence of benefit for using these medications for functional seizures alone.

People with functional seizures should be tapered off these medications if there is not another reason for their use, according to the guideline.

"Many people with functional seizures are initially misdiagnosed with epilepsy and treated with antiseizure medications before the correct diagnosis is made," said guideline author David L. Perez, MD, MMSc, of Harvard Medical School in Boston, Massachusetts, and a Fellow of the American Academy of Neurology.

"Neurologists and other clinicians can use this guideline to help diagnose and manage functional seizures, improving a person's quality of life and brain health overall."

The guideline states that several areas related to functional seizures have limited or no evidence. It also says improved diagnostic techniques are needed and there may be potential for future use of machine learning, artificial intelligence or wearable devices to help with diagnosis.

More information:
Neurology (2025).

Provided by American Academy of Neurology